Missed diagnoses usually stem from basic errors by doctors: study

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Basic errors made by doctors, including tests ordered too late or not at all and failure to create follow-up plans, played a role in nearly 60 per cent of cases in which patients were allegedly hurt by missed or delayed diagnoses, a study found.

Researchersreviewed 307 closed medical malpractice claims, 181 of which allegedly involved diagnostic errors that ended up harming patients. A large majority of those cases involved various types of cancer.

While researchers acknowledged that most claims involved several factors, they said major ones included mistakes by doctors:

Failure to order appropriate diagnostic tests (100 cases).

Failure to create a proper follow-up plan (81).

Failure to obtain an adequate history or perform an adequate physical examination (76).

Incorrect interpretation of tests (67).

Doctors not involved with the study said the findings highlight the fact that physicians— and patients —need to err on the side of caution when it comes to ordering diagnostic tests, keeping detailed records and doing follow-up.

"It seemed like the bottom line was that the problems were problems that would occur less if a person was just very compulsive or very diligent," said Dr. Steven Sorscher, an oncologist at Washington University Medical School in St. Louis. "It highlights the fact that the causes of serious errors are often preventable."

The study's lead author, Dr. Tejal K. Gandhi, director of patient safety at Brigham and Women's Hospital in Boston, said the research shows that doctors could use more help in making decisions.

Helpful stepscould include more use of electronic records, better algorithms for making evaluations and the use of nurse practitioners to help ensure that follow-ups actually occur, she said.

"I don't want to say that it's not the physician's responsibility," Gandhi said. "We think there could be tools to help physicians make these decisions better."

The study looked at random samples of claims from four malpractice insurance companies throughout the U.S. The reviewers were instructed to ignore the outcomes of the claims, all of which closed between 1984 and 2004; nearly 60 per cent of the cases resulted in serious harm and 30 per cent resulted in death. All involved missed or delayed diagnoses in office settings.

Most of the errors occurred in doctor's offices and primary care physicians were those most frequently involved. More than half of the missed diagnoses involved cancer, primarily breast and colorectal cancer, and biopsies were the tests most frequently at issue.

Patients advised to ask questions

The researchers said the leading factors that contributed to errors included failures in judgment (79 per cent), vigilance or memory (59 per cent), knowledge (48 per cent), patient-related factors (46 per cent) and handoffs (20 per cent).

Dr. Edward Langston, chair-elect of the board of the American Medical Association, said doctors have become more aggressive in recent years as far as ordering tests such as biopsies and colonoscopies. They also do more screens even when the patient shows no symptoms, he said.

But the study also showed the importance of patients paying close attention to their care, voicing their opinions and bringing loved ones with them to appointments to help process information and ask questions, he said.

"Communication issues are major issues," said Langston, a primary-care doctor in Lafayette, Ind. "The message is we need to take a hard look at what's happening and how can we decrease it."

The study ispublished in Tuesday's issue of the Annals of Internal Medicine.